ADDRESS

BY

C, EVERETT KOOP, MD, ScD
  SURGEON GENERAL

       OF THE

    U, S, PUBLIC HEALTH SERVICE
U, S, DEPARTMENT OF HEALTH AND HUMAN SERVICES

        PRESENTED TO THE
SECOND ANNUAL CONFERENCE ON SENIOR HEALTH CARE
       SAN DIEGO, CALIFORNIA
     JANUARY 13,p8s]


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(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETCJ

  FIRST, LET ME CONGRATULATE THE PLANNERS OF THIS MEETING FOR
RETURNING TO A TOPIC THAT IS NOW -- AND WILL CONTINUE TO BE -- A
PRIME ISSUE FOR MEDICINE AND PUBLIC HEALTH FOR THE NEXT SEVERAL
DECADES,, ,WELL INTO THE NEXT CENTURY,

  IN FACT, I'D GO SO FAR AS TO SAY THAT MOST HEALTH CARE PLANNING
FOR THE FORESEEABLE FUTURE WILL HAVE TO BE DONE WITH THE AGING
POPULATION PROMINENT IN EVERY EQUATION,

NOW, WHY IS THAT SO?

  THE STATISTICS ARE VERY CLEAR,  I'M NOT GOING TO GO THROUGH A
BUNCH OF THEM NOW, YOU'LL BE GIVEN ENOUGH OF THEM, I'M SURE, BUT
HERE'S ONE THAT ESPECIALLY TICKLES ME:

WE ARE TOLD THAT OVER HALF OF ALL THE PEOPLE WHO FVFR LIVED
BEYOND THE AGE OF 65 IN THIS COUNTRY,, ,ARE ALIVE TODAY,

AND THEN THERE'S THIS ONE:

TODAY THERE ARE 285 MILLION AMERICANS WHO ARE OVER THE AGE OF
85,  AND THAT NUMBER WILL DOUBE BY THE YEAR 2000,


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  AND FOR MOST OF YOU IN THIS AUDIENCE TODAY, LET ME REMIND YOU
THAT THE ODDS ARE RATHER GOOD THAT YOU'LL HAVE THE PRIVILEGE --AND
MAYBF THE PLEASURE -- OF CELEBRATING YOUR OWN 100~~ BIRTHDAY,

  YOUR PROFESSION,,,MINE,,,AND ALL THE PROFESSIONS IN OUR SOCIETY
ARE GOING TO FEEL THE IMPACT OF THE "GRAYING OF AMERICA," THAT'S
CLEAR ENOUGH, BECAUSE IT HAS BEEN UNDERWAY FOR SOMETIME NOW,

  BUT HOW DO WE PREPARE OURSELVES FOR IT? WHAT KIND OF THINKING
DO WE HAVE TO DO?

  I CAN'T SPEAK FOR JOURNALISTS,, aAND A FEW OF MY COLLEAGUES
WOULD PROBABLY SAY I OUGHT NOT TO SPEAK FOR THFM EITHER,

  SO, AS A CONCERNED "OLDER AMERICAN," WHO'S HAD TO LOOK AT THIS
MATTER VERY SERIOUSLY -- SINCE IT BEARS SO DIRECTLY ON THE HEALTH
STATUS OF AMERICANS IN GENERAL -- I'LL TAKE A FEW MINUTES NOW TO
SHARE WITH YOU A FEW OF MY CONCLUSIONS, ,,SOME OF MY FEARS, a aAND SOME
OF MY HOPES,

  FIRST OF ALL, I THINK WE HAVE TO GET RID OF A GREAT NUMBER OF
MYTHS AND OUTWORN STEREOTYPES REGARDING THE ELDERLY,

  FOR EXAMPLE, FOR CENTURIES PEOPLE HAVE TENDED TO CONFUSE THE
AGING PROCESS WITH CERTAIN SPECIFIC DISEASE CONDITIONS THAT JUST
HAPPEN TO BE FOUND MOST OFTEN IN THE ELDERLY,


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  THEREFORE, THEY SAY, WHEN YOU GET OLD, THIS WILL GO AND THAT
WILL GOwBECAUSE YOU'RE GETTING OLD I

BUT MOST OF THAT IS JUST NOT TRUE,  AND NEVER HAS BEEN,

  THE MOST RECENT BIOMEDICAL RESEARCH TELLS US THAT THERE 1s SUCH
A THING AS A DISEASE-FREE AGING PROCESS, IN WHICH ALL SYSTEMS OF THE
HUMAN BODY AND MIND FUNCTION QUITE WELL,

  THE LITERATURE NOW INDICATES THAT PEOPLE DO NOT JUST "RUN DOWN"

AS THEY GET OLDER,

  SOME THINGS NCHANGEmTHAT'S TRUE, BUT MOST NATURAL
FUNCTIONS CONTINUE AND DO NOT NATURAI LY DETERIORATE AS PART OF THE
AGING PROCESS,

  WE HAVE SOMETHING CALLED THE GERONTOLOGY RESEARCH CENTER IN
BALTIMORE, MARYLAND, THE G,R,C, HAS BEEN CARRYING ON A LONGITUDINAL
STUDY OF THE AGING PROCESS FOR ALMOST 30 YEARS, AND IT'S AMAZING THE
KIND OF INFORMATION THAT'S COMING TO LIGHT,

  FOR EXAMPLE, THEY FOUND THAT ABOUT HALF THE ELDERLY SUBJECTS IN
THE STUDY HAD SOME. EVIDENCE OF CORONARY ARTERY DISEASE, WHICH IS NOT
UNCOMMON, OF COURSE, THESE SUBJECTS OBVIOUSLY SHOWED A DECLINE IN
CARDIAC OUTPUT,


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  BUT THERE WERE ALSO A FAIR NUMBER OF ELDERLY SUBJECTS IN THE
SAME AGE COHORT WHO HAD JjQ SIGNS OF CORONARY ARTERY DISEASE AND l!jQ
SIGNS OF A DECLINE IN CARDIAC OUTPUT,

  IN FACT, THEIR CARDIOVASCULAR SYSTEMS WERE FUNCTIONING IN A
MANNER COMPARABLE TO SUCH SYSTEMS FOUND IN PERSONS 20, 30, AND EVEN
JQ YEARS YOUNGER,

  IN OTHER WORDS, THIS RESEARCH -- AND OTHER STUDIES AS WELL --
SEEM TO SHOW THAT A DECLINE IN CARDIAC FUNCTION IS RELATED TO
DISEASLAND IS NOT AN "INEVITABLE" RESULT OF THE THE AGING PROCESS,

  THE BALTIMORE STUDY HAS ALSO SHOWN THAT THE AGING PROCESS DOES
NOT PRODUCE AN "INEVITABLE DECLINE" IN KIDNEY FUNCTION EITHER, AS
IS THE CASE WITH THE HEART, IF THERE IS NO DISEASE CONDITION
PRESENT, THEN THE SYSTEM WILL DO JUST WHAT IT'S SUPPOSED TO DO,

  SO OUR FIRST TASK -- ESPECIALLY THOSE OF US IN MEDICINE AND IN
PUBLIC HEALTH -- IS TO RECOGNIZE A SPECIFIC DISEASE CONDITION FOR
WHAT IT REALLY IS -- A DISEASE CONDITION -- AND NOT ASCRIBE THE
SYMPTOMS OF THAT CONDITION TO THE VAGUE IDEA THAT THE PATIENT "IS,
AFTER ALL, GETTING OLD, a SO, WHAT ELSE CAN YOU EXPECT?"

  THAT'S "BAD MEDICINE," PLAIN AND SIMPLE, AND WE DON'T NEED ANY
MORE OF THAT,


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  BUT BEFORE I GO ANY FURTHER, LET ME OFFER AN IMPORTANT WORD OF

CAUTION:

LET'S NOT GENERALIZE ABOUT THE AGING PROCESS -- WHETHER IT'S
"GOOD NEWS" OR "BAD NEWS,"  THE FACT IS THAT WE'RE STILL JUST AT
THE THRESHOLD OF LEARNING ABOUT IT,

HOWEVER, IF I WERE PUSHED TO THE WALL, AND SOMEBODY ASKED ME TO MAKE
SOME GENERAL OBSERVATIONS AS A FORMER CLINICIAN AND THE CURRENT
SURGEON GENERAL, I'D OFFER JUST THESE TWO:

FIRST, AS I'VE ALREADY INDICATED, THE AGING PROCESS -- WHATEVER
THAT REALLY IS -- IS NOT ITSELF A DISEASE CONDITION AND IS NOT
NECESSARILY ACCOMPANIED BY A DISEASE CONDITION EITHER,

SOMETHING HAPPENS WHEN YOU GET OLD, ,,OF THAT WE CAN BE SURE.
BUT THAT "SOMETHING" DOES NOT YET HAVE A CLEAR LABEL ON IT,
CALLING IT A "DISEASE" IS SIMPLY WRONG,

AND SECONDLY, EACH PERSON GROWS OLDER IN A WAY THAT IS
IT IS DIFFERENT FROM THE
INDIVIDU& AND UNIQUE TO THAT PERSON,
WAY ANYBODY m GROWS OLDER,

  THAT SECOND POINT IS ALSO VERY, VERY IMPORTANT, SOME PERSONS
MAY BE SUSCEPTIBLE TO CERTAIN DISEASE CONDITIONS DURING THE AGING
PROCESS AND THEY HAVE TO BE MONITORED CAREFULLY BY THEIR PHYSICIANS,


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  BUT, WHETHER YOU'RE NMEDICINE OR YOU'RE WRITING ABOUT
MEDICINE, YOU CAN NO LONGER SAFELY GENERALIZE FROM THOSE SPECIFIC,
INDIVIDUAL EXAMPLES,

  I'M SURE MOST OF YOU KNOW THE STORY OF THE 85-YEAR-OLD MAN WHO
LIMPED IN TO SEE HIS DOCTOR AND COMPLAINED OF A SORE LEFT KNEE, AND
THE DOCTOR SAID, "WELL, SIR, WHAT DO YOU EXPECT? YOU'RE 85 YEARS
OLD, THAT'S BOUND TO HAPPEN, ,,AT YOUR AGE m TO WHICH THE ELDERLY
GENTLEMAN REPLIED, "WAIT A MINUTE, DOCTOR.' MY RIGHT KNEE IS JUST AS
OLD AS MY LEFT KNEE, ,,BUT MY RIGHT KNEE DON'T HURT!"

  IT'S TIME FOR u OF US TO ADOPT THE COMMON-SENSE VIEW OF THAT
PATIENT,

  AGE, BY ITSELF, DOES NOT CAUSE DISEASE, AND OLD PEOPLE -- AS A

GROUP -- DO NOT ALL AGE THE SAME WAY,

  THESE TWO GENERALIZATIONS, BY THE WAY, CAN BE APPLIED EQUALLY
TO PHYSICAL SYSTEMS AS WELL AS TO BRAIN FUNCTION,

  HERE AGAIN, WE NEED TO GET RID OF SOME OF OUR PREJUDICES,
THOSE OF YOU WHO HAVE READ BOSWELL'S BIOGRAPHY OF DR, SAMUEL JOHNSON
MAY RECALL THE GOOD DOCTOR'S VIEW OF THE PREJUDICE PEOPLE HAVE

AGAINST THE MENTAL AGILITY OF OLDER PEOPLE:


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"THERE IS A WICKED INCLINATION IN MOST PEOPLE" SAID DRm
JOHNSON, "TO SUPPOSE AN OLD MAN DECAYED IN HIS INTELLECT, IF A
YOUNG OR MIDDLE-AGED MAN, WHEN LEAVING A COMPANY, DOES NOT
RECOLLECT WHERE HE LAID HIS HAT, IT IS NOTHING, BUT IF THE SAME
INATTENTION IS DISCOVERED IN AN OLD MAN' PEOPLE WILL SHRUG THEIR
SHOULDERS AND SAY, 'HIS MEMORY IS GOING."'

  DR, JOHNSON WAS A SHARP OBSERVER OF HUMAN NATURE WHO WAS NOT
ALWAYS APPRECIATED IN HIS OWN TIME, BUT, FOR MY MONEY, THAT ONE
OBSERVATION ABOUT YOUTH AND AGE WOULD HAVE MADE HIM A MOST WELCOME
FAMILY PHYSICIAN -- OR MEDICAL JOURNALIST -- TODAY,

  DR, JOHNSON KNEW YESTERDAY. BY INTUITION, WHAT WE ARE FINDING TO
BE TRUE TODAY THROUGH SCIENCE,
    WE NOW KNOW THAT BRAIN METABOLISM
AND MENTAL FUNCTIONS DO NOT 'NATURALLY' DETERIORATE WITH AGE,

  IN FACT, IN A STUDY CARRIED OUT IN THE STATE OF WASHINGTON' THE
RESEARCHERS GAVE THEIR SUBJECTS A BATTERY OF INTELLIGENCE TESTS OVER
A 20-YEAR PERIOD AND THEY DISCOVERED THAT 80 PERCENT OF THE SUBJECTS
SHOWED NO REAL CHANGE IN MENTAL PFRFORMANCE OVER THAT PERIOD OF
TIME,

  I DON'T KNOW ABOUT YOU, BUT 1 FEEL A WHOLE LOT BETTER KNOWING
ABOUT THAT STUDY,


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  ALL THIS TALK OF BRAIN FUNCTION REMINDS US OF THE PRESENCE OF
ALZHEIMER'S DISEASE THAT STRIKES SOME 2'5 MILLION OLDER AMERICANS
EVERY YEAR,

  AND WE'RE ONLY NOW LEARNING ABOUT ALZHEIMER'S FROM A SMALL ARMY
OF RESEARCHERS, THEIR RESEARCH IS EXTREMELY IMPORTANT FOR A COUPLE
OF REASONS:

*

  FIRST OF ALL, WE'RE GETTING TO KNOW MORE ABOUT ALZHEIMER'S
DISEASE SO THAT WE CAN ATTEMPT TO TREAT IT AND MAYBE ONE DAY
PREVENT IT FROM OCCURRING ALTOGETHER,

+

  AND SECONDLY, THE RESEARCH IS REVEALING TO US THAT THERE
ARE CERTAIN MINOR, BENIGN, AND NATURAI. CHANGES IN COGNITION THAT
TAKE PLACEwOVER TIMEwDURING THE AGING PROCESS THESE
CHANGES ARE NOT THEMSELVES DISEASE CONDITIONS, NOR DO THEY SEEM
TO BE PRECURSORS OF DISEASE EITHER,

  AND ONE FINAL POINT, AND THIS HAS TO DO WITH LONG-TERM
PLANNING FOR OUR NATIONAL HEALTH POLICY, I KNOW THAT A NUMBER OF
YOU ARE ALSO INTERESTED IN WRITING IN THIS ASPECT OF THE FIELD OF
AGING,

  IT SEEMS THAT PHYSICIANS HAVE TENDED TO MISTAKE MANY NORMAL
ASPECTS OF THE AGING PROCESS FOR A VARIETY OF DISEASE CONDITIONS,
THAT'S A VALID CONCLUSION TO DRAW FROM MUCH OF THE RESEARCH THAT'S
BEEN GOING ON,


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  IF THAT IS INDEED THE CASE, THEN IT MEANS WE'RE PROBABLY OVER-
DIAGNOSING OUR OLDER PATIENTS,

  AND IF WE ARE DOING THAT, THEN MAYBE IT'S TIME FOR US TO RE-
WRITE AT LEAST SOME OF OUR PREDICTIONS ABOUT THE BURDEN OF ILLNESS
IN AMERICA IN THE 21ST CENTURY, WE MAY NOT BE LOOKING AHEAD TO A
WORST-CASE SITUATION AFTER ALL,

  AND I TEND TO THINK THAT THAT MAY WELL BE TRUE,,,FOR QUITE
DIFFERENT REASONS,

  FOR EXAMPLE, TODAY'S WORKING ADULT IS GENERALLY IN GOOD
HEALTH, IN FACT, THE OVERALL `HEALTH STATUS OF ADULT AMERICANS IS
REALLY QUITE GOOD,, ,NEVER BEEN BETTER,

   THEY -- YOU -- ARE BENEFITTING FROM BETTER DIET, FROM LOTS OF
REGULAR EXERCISE, AND FROM A NOTICEABLE AND CONTINUING DECLINE IN
ALCOHOL INTAKE AND CIGARETTE SMOKING,

  THESE AND OTHER LIFESTYLE CHANGES INDICATE THAT TODAY'S WORKING
ADULTS HAVE A BETTER PROGNOSIS FOR CONTINUED GOOD HEALTH AFTER AGE
65 THAN FOR ANY PREVIOUS GENERATION EVER HAD,

   IN OTHER WORDS, FOR TODAY'S YOUNG WORKING ADULTS, THE POSSI-
BILITIES ARE VERY GOOD THAT THEY MIGHT HAVE A RELATIVELY DISEASE-
FREE OLD AGE IN THE DECADES AHEAD,


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  SO THAT'S ANOTHER REASON WHY WE MIGHT BE LOOKING FORWARD TO A
RELATIVELY LOWE& MORBIDITY BURDEN OVERALL IN THE 21ST CENTURY FOR
OUR OLDER CITIZENS,

  LET ME EMPHASIZE THAT THESE ARE JUST EDUCATED GUESSES, BUT I DO
BELIEVE THAT THEY ARE, NEVERTHELESS, IMPORTANT STRAWS IN THE WIND.
AND, IN ANY CASE, SUCH CONJECTURE IS EXTREMELY IMPORTANT, IF YOU

PROBE A BIT FURTHER INTO THE ISSUE OF HEALTH CARE FOR THE AGED AND
CONFRONT THE MATTER OF DEATH AND DYING -- THE ISSUE OF "DEATH WITH

DIGNITY" -- AND THE MATTER OF THE COST OF CARING FOR THE AGED
TERMINALLY ILL PERSON,

  FOR EXAMPLE, MANY TERMINAL ILLNESSES AMONG THE ELDERLY ARE
TOTALLY OR SUBSTANTIALLY THE CONSEQUENCE OF CERTAIN PATTERNS OF
LIVING, SMOKING IS A GOOD CASE IN POINT,

*

  OUR RESEARCH INDICATES THAT, OF THE HALF-MILLION OR MORE
PEOPLE WHO DIE EACH YEAR OF CORONARY HEART DISEASE, CLOSE TO 30
PERCENT -- OR ABOUT 170,000 OF THOSE DEATHS -- WERE CIGARETTE
SMOKERS,

*

  OF THE 60,000 OR SO AMERICANS WHO DIE OF CHRONIC
OBSTRUCTIVE LUNG DISEASE, CLOSE TO 90 PERCENT WERE CIGARETTE
SMOKERS,


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*   AND OF THE 430,000 DEATHS FROM CANCER, AGAIN ABOUT 30

PERCENT -- OR 129,000 DEATHS -- ARE ATTRIBUTABLE TO CIGARETTE

SMOKING,

  OTHER LIFESTYLE FACTORS IN PREMATURE DEATHS AMONG THE ELDERLY
WOULD INCLUDE DIET AND NUTRITION, EXERCISE, AND ENVIRONMENTAL
HAZARDS, BOTH IN THE HOME AND AT THE WORKPLACE,

  MANY OF TODAY'S AILING, DEPENDENT, AND EVEN HOSPITALIZED
ELDERLY ARE, THEN, VICTIMS -- TO A MARKED DEGREE -- OF BOTH THE
ENVIRONMENT, INCLUDING THE SEDUCTIVE MARKETPLACE' AND THEIR OWN POOR

JUDGMENT,

  AND THAT'S THE CRUX OF THE ARGUMENT, ISN'T IT, IN ALL THE
LIABILITY CASES BEING BROUGHT AGAINST THE CIGARETTE COMPANIES:

THAT IS' TO WHAT EXTENT ARE THE COMPANIES CULPABLE AND TO WHAT
EXTENT ARE THE INDIVIDUAL SMOKERS CULPABLE?

THERE'S A DOLLAR SIGN HANGING OFF THAT QUESTIONwNOT JUST THE
DOLLARS THE COMPANIES MIGHT HAVE TO PAY, BUT THE DOLLARS THE
AMERICAN TAXPAYER MUST PAY TO PROVIDE DECENT, APPROPRIATE HEALTH
CARE FOR THE TERMINALLY ILL, OLDER PERSON,

  THERE IS A LOT OF TALK THESE DAYS ABOUT THE TERRIBLE MEDICAL
EXPENSE IN THE LAST YEAR OF LIFE, I DON'T KNOW WHY THAT SURPRISES
PEOPLE,


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  WE KNOW THAT THE FIRST YEAR OF LIFE CAN BE EXTRAORDINARILY
EXPENSIVE FOR A NEONATE,  WHY NOT ACCEPT THE FIN& YEAR OF LIFE AS
BEING EQUALLY TOUGH ON THE POCKETBOOK?

  THE REAL QUESTION TO ASK IS THIS: "ARE WE SPENDING THE MONEY
PROPERLY?" AND I WOULD ADD THAT "PROPERLY" WOULD MEAN WITH NOT ONLY
THE PATIENT IN MIND BUT ALSO THE FAMILY, THE COMMUNITY, AND THE
HEALTH PROFESSIONALS INVOLVED,

  SOME OLDER HEART DISEASE AND STROKE PATIENTS HAVE BEEN KNOWN TO
LINGER FOR A YEAR OR MORE, IN A "VEGETATIVE" STATEmmA TERM THAT IS
NOT EASY TO PIN DOWN, AND MANY PEOPLE -- PRINCIPALLY ECONOMISTS,
ATTORNEYS, AND SOME POLITICIANS -- HAVE BEGUN TO DISCUSS THE SOCIAL
NEED TO PROVIDE SUCH COSTLY IN-PATIENT CARE TO TEMRINALLY ILL, OLDER
PEOPLE,

  GOVERNOR LAMM OF COLORADO WAS THE MOST BLUNT ABOUT IT: THEY
OUGHT TO DIE MORE QUICKLY AND "GET OUT OF THE WAY," HE SAID,

  AT THE VERY LEAST, THESE PEOPLE ARGUE, OLD PEOPLE OUGHT TO HAVE
THE RIGHT TO INDICATE THAT SUCH IS THEIR CHOICE IN THE MATTER,

  AND JUST AS AN ASIDE, I SHOULD SAY THAT THAT PHRASE -- "THEIR
CHOICE" -- HAS ALWAYS MADE ME A LITTLE NERVOUS, BECAUSE I KNOW HOW
OFTEN IT IS SOMEONE ELSE'S CHOICE, IN FACT, IN 1978 I MADE A MOVE
ENTITLED DEATH BY SOMEONE'S CHOICE I


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  VARIOUS "LIVING WILLS" AND "MEDICAL POWERS OF ATTORNEY" ARE
CITED NOWADAYS AS BEING THE KINDS OF THE DOCUMENTS THAT EXPRESS AN
INDIVIDUAL'S PERSONAL CHOICE FOR A SO-CALLED "DEATH WITH DIGNITY,"

  BUT WHEN PUSH COMES TO SHOVE, AND A PATIENT FACES THE CHOICE OF
THE KIND OF LIFE HE OR SHE IS LIVING OR A "DEATH WITH DIGNITY," THE
PATIENT VERY OFTEN CHOOSES LIFE OVER DEATH, BUT IF HE OR SHE HAD
ALREADY SIGNED A DOCUMENT REQUESTING DEATH, THAT PATIENT MIGHT WELL
BE STUCK WITH IT,

  INCIDENTALLY, THERES NOTHING WRONG WITH A PERSON WHO DOES NOT
AGREE WITH GOVERNOR LAMM AND DOES NOT WANT TO "GET OUT OF THE
WAY,"  WITH OR WITHOUT THE PROPER DOCUMENTATION,

  NOW, I GRANT YYOU THAT SOME OLDER FOLKS HAVE THE POOR TASTE TO
TAKE A LONG TIME DYING OF ONE DISEASE OR ANOTHER, I THINK IT WAS
DANIEL CALLAHAN OF THE HASTING CENTER WHO GAVE THIS GROUP OF PEOPLE
A MARVELOUS NAME: HE CALLED THEM THE "BIOLOGICALLY TENACIOUS,"

  THEY COME IN ALL AGES AND SIZES, ALL RACES, AND BOTH SEXES,
BUT MOST OF THEM ARE OLD, THEY CONSUME MORE THAN THEIR SHARE OF OUR
SYMPATHY AND TECHNOLOGY -- AND HARD CASH,

THEY ARE A DRAIN ON US,

  BUT SHOULD WE KILL THEM? SHOULD WE "PULL THE PLUG" BECAUSE
THEY ARE OLD AND STUBBORN?


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  ON THE OTHER HAND, SHOULD WE LET THEIR DISEASE DRAG ON AND ON
UNTIL IT RUNS ITS NORMAL COURSE,, ,AND THOSE PATIENTS FINALLY DIE AS
PREDICTED?

   I MUST CONFESS THAT I AM VERY UNCOMFORTABLE WITH THE WINDSTORM
OF ARGUMENT IN FAVOR OF "DEATH WITH DIGNITY," I THINK IT COULD BE
ALLOWING EUTHANASIA TO GET A FOOT IN THE DOOR, IT'S JUST ANOTHER
WAY OF ALLOWING SOCIETY TO GET RID OF PEOPLE WHO ARE AN EMBARRASS-
MENT OR A PUZZLE OR A DRAG OR A LIABILITY,

  BUT LET'S MAKE ONE THING CLEAR, WE'RE NOT TALKING ABOUT
ZMMORTALITY FOR EVERYONE EITHER, I HAVE A FAVORTIE LINE I USE WHEN
TALKING TO FRIENDS MY AGE WHO COMPLAIN ABOUT BEING SICK,  I SAY TO

THEM: "YOU'VE GOT TO DIE OF SOMETHING,"

  THERE'S A GREAT DEAL OF DIFFERENCE BETWEEN GIVING A PATIENT ALL
THE LIFE TO WHICH HE OR SHE IS ENTITLED AND MERELY PROLONGING THE
ACT OF DYING, THAT'S WHAT I MEAN WHEN I SAY, "YOU'VE GOT TO DIE OF
SOMETHING,"

  MANY OF THOSE GREAT EXPENDITURES FOR HEALTH CARE MADE IN THE
LAST YEAR OF A PERSON'S LIFE ARE OFTEN MADE IN THE FUTILE PURSUIT OF
PROLONGING THE PATIENT'S ACT OF DYING, ON THE OTHER HAND, OTHER
EXPENDITURES ARE MADE FOR PATIENTS FOR WHOM THERE IS A HIGH
EXPECTATION OF RECOVERY,


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  THESE TWO TYPES OF PATIENTS NEED TO BE SEPARATED IN OUR
MINDS, THEY PRESENT TWO DIFFERNT KINDS OF PROBLEMS, AND THEY MUST
BE DEALT WITH ETHICALLY AND MORALLY ON THE BASIS OF MEDICAL
PROGNOSIS, AND NOT ON THE BASIS OF HIGH COST OR LOW COST OR "COST
CONTAINMENT,"

  FRANKLY, I WORRY A GREAT DEAL ABOUT AN AMERICA THAT WILL DECIDE
SUCH A GREAT ETHICAL ISSUE OF LIFE AND DEATH ALMOST EXCLUSIVELY IN
TERMS OF "COST CONTAINMENT,"

  TODAY -- AND FOR THE NEXT DECADE OR SO -- THE OLDER PEOPLE WITH
TERMINAL ILLNESSES ARE GOING TO BE A VERY LARGE BURDEN UPON US, I
BELIEVE IT IS AN INESCAPABLE BURDENwONE THAT DEFIES ANY "QUICK
FIX" . ,,A BURDEN THAT WILL CONTINUE TO TAX OUR MORALITY AS WELL AS
OUR TREASURY,

  AND I'M WILLING TO PAY MY SHARE, TODAY, I'M 71 YEARS OLD, BUT
I TRULY BELIEVE I WOULD HAVE SAID THE SAME THING WHEN I WAS NYEARS
OLD,

  I DON'T LIKE THE ALTERNATIVES THAT HAVE BEEN OFFERED SO FAR,
THEY HAVE ALL THE CHARACTERISTICS OF VERY FLIMSY ETHICS,,,AND THEY
LEAD DIRECTLY TO THAT SLIPPERY SLOPE OF DOING MORE AND MORE TO
POSTPONE OR OUTRIGHTLY AVOID HUMAN, INTERPERSONAL RESPONSIBILITY.


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  THERE'S PHYSICAL HEALTH, a aTHERE'S MENTAL HEALTH,, #BUT THERE'S
ALSO ETHICAL, MORAL, AND SPIRITUAL HEALTH, I DON'T BELIEVE YOU CAN
FORSAKE m OF THEM, WITHOUT JEOPARDIZING AND ULTIMATELY FORSAKING
THEM ALL,

  EARLIER, I IMPLIED THE POSSIBILITY THAT THE OVERALL HEALTH COST
OF TOMORROW'S ELDERLY MAY BE SUBSTANTIALLY LOWER, PER CAPITA, THAN
IT IS TODAY, THANKS TO A POPULAR COMMITMENT TO HEALTH PROMOTION AND
THE PREVENTION OF DISEASE AND DISABILITY BY BOTH THE INDIVIDUAL AND
SOCIETY,

  OBVIOUSLY, IF THAT IS TRUE, THEN A GREAT DEAL OF HAND-WRINGING
IN REGARD TO COST CONTAINMENT WILL NO LONGER BE NECESSARY, BUT
THAT'S SOMEWHERE IN THE FUTRE,,,THE YEAR 2020 OR EVEN 2025,

  WHAT DO WE DO IN THE INTERIMmuTHAT PERIOD OF TIME WHICH IS
WHERE WE ALL NOW LIVE?

  I COME TO YOU WITH THIS QUESTION,,,AND I'M AFRAID THAT, LIKE
MOST OF YOU HERE TODAY, I DON'T HAVE ANY AIR-TIGHT ANSWERS,

  FOR ONE THING, WE KEEP TALKING ABOUT THESE ISSUES AFFECTING THE
ELDERLY IN TERMS ALMOST EXCLUSIVELY MEDICAL OR ECONOMIC, BUT WE'VE
GOT TO BROADEN THE TERMS OF THE ARGUMENT,


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WE'VE GOT TO BROADEN THE DISCUSSION TO EMBRACE THE ISSUES OF,,,

THE RIGHT OF EACH INDIVIDUAL TO LIVE AS WELL AS TO DIE,,,

OF THE NEED TO PROTECT THE INDIVIDUAL FROM THE PRAGMATIC -- BUT
PERHAPS, AT TIMES, UNETHICAL -- PERCEPTIONS OF -- FOR WANT OF A
BETTER TERM -- "THE ELECTORATE", ,.

AND THE ULTIMATE ISSUE OF ALL: WHAT KIND OF SOCIETY DO WE REALLY

WANT TO BE?

  I DON'T ENVY YOU YOUR JOB IN EXPLAINING THIS COMPLEX SET OF
ISSUES -- DAY AFTER DAY -- IN PRINT OR ON THE RADIO OR THE
TELEVISION, IT'S NOT THAT EASY FOR KTO HANDLE EITHER, STANDING
HERE TODAY AS YOUR SURGEON GENERAL,

  BUT WE CAN'T DUCK THESE ISSUES JUST BECAUSE THEY ARE
INCONVENIENTLY DIFFICULT,


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  AND I WILL REMIND YOU THAT, IF YOU IJQDUCK THEM, THEY WILL ONLY
COME BACK TO HAUNT YOU WHEN YOU, TOO, ARE OLDwAND ILLwAND IN
NEED OF COMPASSIONATE HEALTH CARE TO EASE YOU THROUGH YOUR FINAL
DAYS, #aHOWEVER MANY OF THEM THERE MAY BE, ,,HOWEVER COSTLY THEY MAY
BEwAND HOWEVER PLEASANT OR WLEASANT YOU MAY BE BY THAT TIME,

  TODAY, HOWEVER, YOU'VE BEEN A VERY PIFASANT AUDIENCE AND I'M
DELIGHTED TO HAVE HAD THIS MOMENT TO SHARE THESE FEW IDEAS WITH YOU,

THANK YOU,
              #####